5 Preface Dear Passionate Endoscopists, Image-enhanced endoscopy has been developed far beyond our expectation. It seems that the quotation by Albert Einstein imagination is more important than knowledge is also true for GI Endoscopy. This latest book series of Atlas in GI Endoscopy by TAGE provides a case series of GI Endoscopy from top to bottom (upper GI, HPB, and lower GI Endoscopy). It includes many fantastic images with high quality obtained by EVIS EXERA III-190 HD (Olympus Medical). This case series provide not only the advancement in the Art and Knowledge of GI Endoscopy but also all the related radiology and pathology. I would like to take this opportunity to express my deeply thanks to the editors, Professor Rungsun Rerknimitr, Associated Professor Sombat Treeprasertsuk, Dr.Linda Pantongrag-Brown and colleagues who contribute their great efforts to make this important 6th edition of the GI Endoscopy atlas available under the TAGE support. Last but not least, I hope that you will enjoy learning and reading this book and this in turn will ultimately help your daily practice at certain level. Dr. Thawee Ratanachu-Ek, M.D. TAGE President

6 From Editors Gastro-intestinal endoscopy knowledge and technologies have significantly changed over the last few decades. Many new endoscopic findings has been discovered and effectively used for both diagnostic and the treatment purpose. Nevertheless, it is still difficult for beginners to learn about these endoscopic findings within a short period of time. Especially, in uncommon diseases, trainees may have never seen those lesions during their training time. A helpful endoscopic atlas with a brief summary of the case followed by a practical discussion is an invaluable resource for learners including gastroenterologists, surgeons, internists, nurses and all GI paramedics. This book was written by our faculties of the excellence center of GI Endoscopy, Chulalongkorn University. This version is the sixth edition and consists of 4 section including upper GI endoscopy, lower GI endoscopy, ERCP, and EUS. It comes in a package of interesting presentations. Each case will be displayed with an intriguing image findings and followed by the literature review of such case. Systematic indexing of all case scenarios will help the readers to search for the most appropriate cases within a few minutes. However, reading through all cases probably the most valuable way. We hope that the book will help our readers to improve the practice and clinical knowledge and all readers would enjoy the content of this New Bowel image (NBI) atlas.

17 Case 4 Sasipim Sallapant, M.D. Rapat Pittayanon, M.D., M.Sc. Rungsun Rerknimitr, M.D. A 50-year-old male with previously healthy admitted in the surgical department due to gastric ulcer perforation. He underwent exploratory laparotomy with simple suture and omental patch. One week after operation, he developed acute hematemesis with postural hypotension. Emergency EGD was performed and showed multiple long linear esophageal ulcers and erosions with bridging of mucosal folds extending from mid esophagus to gastroesophageal junction (Figure 1). There are moderate amount of blood clot in the esophagus. The stomach and duodenum revealed neither erosion nor ulcer. He was treated with NPO, intravenous fluid, high dose proton pump inhibitors as well as a head elevation. After a few days of treatment, the symptom improved and the enteral feeding was initiated. He had no recurrent upper GI bleeding. Figure 1 Severe reflux esophagitis 7

18 Diagnosis: Upper GI bleeding from severe reflux esophagitis, LA classification grade C Discussion: Bleeding reflux esophagitis is usually associated with deep esophageal ulcers or severe esophagitis (LA classification grades C and D). 1 Clinical presentation can ranges from active GI bleeding to iron deficiency anemia. Clinically important hemorrhage has been reported in 7% to 18% of GERD patients. 2 A history of reflux esophagitis or heartburn was noted in only 28% or 37% of the patients with bleeding reflux esophagitis. Severe bleeding from reflux esophagitis is treated medically with a proton pump inhibitor (PPI). The patient should be treated with a minimum 8-week course. Head of bed elevation and avoidance of meals 2 3 hours before bedtime are recommended. 3 EGD is critical for diagnosis of the bleeding etiology, but endoscopic treatment generally has not been required in this setting unless a focal ulcer with a stigma of recent hemorrhage was found. 4 Repeat endoscopy should be performed in patients with severe erosive reflux disease after a course of PPI therapy to exclude underlying Barrett s esophagus. 3 References 1. Higuchi D, Sagawa C, Shab SH, et al. Etiology, treatment and outcome of esophageal ulcers: A 10 year experience in an urban emergency hospital. J Gastrointest Surg 2003;7: Costa ND, Cadiot G, Merle C, et al. Bleeding reflux esophagitis: a prospective 1-year study in a university hospital. Am J Gastroenterol 2001;96: Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol 2013;108: Wang JH, Fisher DA, Ben-Menachem T, et al. The role of endoscopy in the management of acute non-variceal upper GI bleeding. Gastrointest Endosc 2012;75:

21 Case 6 Piyapan Prueksapanich, M.D. Rapat Pittayanon, M.D., M.Sc. Nareumon Wisedopas, M.D. Rungsun Rerknimitr, M.D. A 63-year-old male with a history of complete remission of stage III supraglottic squamous cell carcinoma for one year underwent a surveillance EGD for esophageal cancer. He was asymptomatic, EGD showed a flat and irregular boarder lesion at cm from the incisor with fungating mass sized 1.5 cm on-top (Figure 1). NBI confirmed as a well-defined brownish lesion (Figure 2) with abnormal intrapapillary capillary loops (IPCLs). The IPCLs characters showed tortuous, dilated, irregular caliber, and various in shapes of capillary loops with some avascular area (Figure 3). The NBI finding of the IPCLs was compatible with carcinoma in situ according to the Inoue s classification. After Lugol solution staining, the lesion was unstained and the border was more clearly defined (Figure 4). The lesion was biopsied with the biopsy forceps. Pathology showed well-differentiated squamous cell carcinoma with no basement membrane penetration which was compatible with Tis staging (carcinoma insitu) (Figure 5). Figure 1 EGD showed a flat and irregular boarder lesion at cm from the incisor with a fungating mass sized 1.5 cm on-top. 11

22 Figure 2 With NBI mode, the lesion was seen as a well-defined brownish lesion. Figure 3 The IPCLs pattern showed tortuous, dilated, irregular caliber and various in shapes of capillaries with some avascular area. Figure 4 After a Lugol solution staining, the lesion was unstained and the border was well demarcated (arrow). Figure 5 Pathology demonstrated well-differentiated squamous cell carcinoma with no basement membrane penetration compatible. 12

23 Diagnosis: Esophageal squamous cell carcinoma in situ Discussion: The metachronous squamous cell carcinoma of esophagus can be developed in the patient with history of head and neck cancer according to the field cancerization hypothesis. 1 Early detection of the second primary esophageal cancer in these patients was a key to improve the prognosis. Chromoendoscopy with Lugol s solution has an excellent sensitivity to detect the early esophageal cancer in this group of patients. 2 Narrow band imaging has comparable performance with additional ability to charactereize the lesion by the IPCLs pattern. 3 References 1. Slaughter DP, Southwick HW, Smejkal W. Field cancerization in oral stratified squamous epithelium; clinical implications of multicentric origin. Cancer 1953;6: Hashimoto CL, Iriya K, Baba ER, et al. Lugol s dye spray chromoendoscopy establishes early diagnosis of esophageal cancer in patients with primary head and neck cancer. Am J Gastroenterol 2005;100: Uedo N, Fujishiro M, Goda K,et al. Role of narrow band imaging for diagnosis of early-stage esophagogastric cancer: current consensus of experienced endoscopists in Asia-Pacific region. Dig Endosc 2011;23 Suppl 1:

24 Case 7 Suppakorn Malikhao, M.D. Boonlert Imraporn, M.D. Rapat Pittayanon, M.D., M.Sc. Rungsun Rerknimitr, M.D. A 70-year-old male presented with a longstanding history of heartburn, regurgitation and dyspeptic symptoms. EGD found a lower esophageal ring at the esophagogastric junction with a sliding hiatal hernia. This esophageal ring is characterized by thin concentric protrusions covered proximally by normal esophageal epithelium and on the distal side of the membrane was covered by gastric epithelium (Figure 1). Figure 1 EGD showed a lower esophageal ring at the esophagogastric junction. 14

25 Diagnosis: Schatzki s ring Discussion: Schatzki s ring, B type esophageal ring, is the most common esophageal ring found on either barium radiographs or endoscopy. The pathogenesis and etiology remain controversial. 1 Although most of Schatzki s rings are asymptomatic, they can be the cause of episodic dysphagia for solids and food impaction regarding to the narrowing esophageal lumen if the diameter is less than 13 mm in diameter. 2 In those symptomatic patients, esophageal dilatation is the mainstay of therapy. 1 References 1. Advances in GERD: Current Developments in the Management of Acid-Related GI Disorders. Gastroenterol Hepatol (N Y) 2010;6: Muller M, Gockel I, Hedwig P, et al. Is the Schatzki ring a unique esophageal entity? World J Gastroenterol 2011;17:

26 Case 8 Sayamon Kimtrakool, M.D. Rapat Pittayanon, M.D., M.Sc. Rungsun Rerknimitr, M.D. A 54-year-old Thai male with underlying alcoholic cirrhosis child B was transferred to the emergency room due to hematemesis for 4 hours. An emergency EGD revealed a pulsatile bleeding from a small esophageal varix at the distal esophagus. Endoscopic variceal ligation (EVL) was not successfully able to control the bleeding at the first attempt due to a small size of varix on the post EVL scar. Then, N-butyl- 2-cyanoacrylate (Histoacryl) 0.5 ml mixed with Lipiodol 0.8 ml was injected at the bleeding point and eventually bleeding stopped. At four days after the procedure, EGD was repeated as a second-look EGD. It revealed only a superficial solitary ulcer with necrotic area, representing the healing process from previous glue injection. After a few days of supportive treatments, his hematocrit was stabilized and finally discharged from the hospital. Figures 1 and 2 EGD showed a superficial solitary ulcer with necrotic area resulting from the prior glue injection (arrow). 16

28 Case 9 Piyachai Orkoonsawat, M.D. Rapat Pittayanon, M.D., M.Sc. Rungsun Rerknimitr, M.D. A 70-year-old male with a history of stage I squamous cell carcinoma of the oral cavity for a year came for esophageal cancer surveillance. He reported no upper GI symptom. EGD exam was unremarkable under the white light mode. After Lugol s iodine staining, a well-demarcated depressed mucosa was observed at the proximal esophagus. Under NBI exam, it showed a 1x3 cm, well-demarcated purplish area (Figure 1). Under magnifying NBI, the abnormal pattern of the intraepithelial papillary capillary loop (IPCL) was clearly demonstrated including dilatation, tortuosity, variation in the shape and caliber of IPCL which were compatible with neoplasia (Figure 2). Biopsy was done and pathology showed a high grade dysplasia. Subsequently, an endoscopic mucosal resection (EMR) was carried on. Cap-assisted esophageal EMR was done by using a crescent (Duck bill) snare (Figure 3). No active bleeding developed after the procedure (Figure 4). Figure 1 NBI showed a 1x3 cm, well-demarcated with puplish color of the unstained lugol area. 18

29 Figure 2 Figure 3 Figure 2 Magnifying NBI showed dilatation, tortuosity, variation in the shape and calibre of the intrae-pithelial papillary capillary loop (IPCL) (arrow). Figure 3 Cap-assisted esophageal EMR was done by using a crescent (Duck bill) snare. Figure 4 Figure 4 Post cap-assisted esophageal EMR without active bleeding. Diagnosis: High grade dysplasia of the second primary esophageal squamous cell neoplasm treated with an endoscopic mucosal resection (EMR) Discussion: Head and neck squamous cell carcinomas patients have a high risk of developing other neoplasms either simultaneously or subsequently. The incidence of second primary esophageal squamous cell carcinoma (ESCC) was reported as 9%- 44%. 1 The treatment for early ESCC including high grade dysplasia when it is limited to the superficial layers of the mucosa and also measures less than 2 cm in extension with involvement less than 1/3 of the circumference is EMR. With a complete en-bloc resection, the 5-year survival rate is up to 95%. 2, 3 19

Gastrointestinal Bleeding Introduction Gastrointestinal bleeding is a symptom of many diseases rather than a disease itself. A number of different conditions can cause gastrointestinal bleeding. Some causes

POEM Procedure for Esophageal Achalasia POEM (Per-Oral endoscopic myotomy) is an incisionless procedure to treat esophageal achalasia, totally performed by endoscopy, without cutting the surface of the

Bleeding in the Digestive Tract Bleeding in the digestive tract is a symptom of a disease rather than a disease itself. Bleeding can occur as the result of a number of different conditions, some of which

The digestive system Medicine and technology Normal structure and function Diagnostic methods Example diseases and therapies The digestive system An overview (1) Oesophagus Liver (hepar) Biliary system

Bleeding in the Digestive Tract National Digestive Diseases Information Clearinghouse U.S. Department of Health and Human Services NATIONAL INSTITUTES OF HEALTH Bleeding in the digestive tract is a symptom

WHAT S WRONG WITH MY GALL BLADDER? GALL BLADDER POLYPS This is a patient information booklet providing specific practical information about gall bladder polyps in brief. Its aim is to provide the patient

ESOPHAGEAL DISORDERS LEARNING OBJECTIVES At the end of the lecture student should be able to Know the quick overview of Anatomy and Physiology of Esophagus Know the common esophageal disorders Know the

PATIENT EDUCATION patienteducation.osumc.edu What is the esophagus? The esophagus (food pipe) is a tube that connects your throat to your stomach. It is about 10 inches long and runs behind your trachea

GASTROESOPHAGEAL REFLUX DISEASE (GERD) Gastroesophageal reflux disease is a clinical scenario where the gastric or duodenal contents reflux back up into the esophagus. Reflux esophagitis, however, is a

Barrett s Esophagus What is Barrett s esophagus? Barrett s esophagus is a pre-cancerous condition affecting the lining of the esophagus, the swallowing tube that carries foods and liquids from the mouth

Section of Pathology and Tumour Biology How to report Upper GI EMR/ESD specimens Dr.H.Grabsch Warning. Most of the criteria, methodologies, evidence presented in this talk are based on studies in early

American College of Gastroenterology Digestive Disease Specialists Committed to Quality in Patient Care Common Gastrointestinal Problems A Consumer Health Guide GASTROESOPHAGEAL REFLUX DISEASE (GERD) What

Intestinal Cancer Introduction This reference summary discusses cancer of the small intestines, not cancer of the colon. Intestinal cancer starts in the cells of the small intestine. The small intestine

SMALL BOWEL BLEEDING: CAUSES, DIAGNOSIS AND TREATMENT By Anne C. Travis, M.D., M.Sc. and John R. Saltzman, M.D., FACG Brigham and Women's Hospital Harvard Medical School Boston, MA 1. What is the small

Liver Cancer What is the liver? The liver is the largest internal organ in the body and is important in digesting food. The liver performs many other functions, including collecting and filtering blood

Gallbladder cancer Gallbladder cancer is a disease in which malignant (cancer) cells form in the tissues of the gallbladder. Gallbladder cancer is a rare disease in which malignant (cancer) cells are found

EXTRAHEPATIC BILE DUCT CANCER General Information Extrahepatic bile duct cancer is a rare disease in which malignant (cancer) cells form in the part of bile duct that is outside the liver. A network of

Informed Consent for Laparoscopic Vertical Sleeve Gastrectomy Patient Name Please read this form carefully and ask about anything you may not understand. I consent to have a laparoscopic Vertical Sleeve

LIVER CANCER AND TUMOURS LIVER CANCER AND TUMOURS Healthy Liver Cirrhotic Liver Tumour What causes liver cancer? Many factors may play a role in the development of cancer. Because the liver filters blood

Chapter 6 Gastrointestinal This chapter consists of 2 parts: Part 6.1 Diseases of the digestive system Part 6.2 Abdominal wall hernias and obesity PART 6.1: DISEASES OF THE DIGESTIVE SYSTEM Diseases of

Understanding Pancreatic Cancer Understanding Pancreatic Cancer The Pancreas The pancreas is an organ that is about 6 inches long. It s located deep in your belly between your stomach and backbone. Your

Clinical Analysis of Focal Nodular Hyperplasia of the Liver in 11 Patients Purpose: The purpose of this study was to determine the clinical features of focal nodular hyperplasia (FNH) and investigate its

Liver Cancer And Tumours What causes liver cancer? Many factors may play a role in the development of cancer. Because the liver filters blood from all parts of the body, cancer cells from elsewhere can

Therapeutic Endoscopy Fantastic Voyage Now a Reality Robert Luís Pompa, MD Gastroenterology History of Endoscopy Two major obstacles: The gut is not straight It s dark in there! Dr. Kussmaul 1868 first

Laparoscopic Surgery of the Colon and Rectum (Large Intestine) A Simple Guide to Help Answer Your Questions What are the Colon and Rectum? The colon and rectum together make up the large intestine. After

Lenox Hill Hospital Department of Surgery General Surgery Goals and Objectives Medical Knowledge and Patient Care: Residents must demonstrate knowledge and application of the pathophysiology and epidemiology

Pancreatic Cancer Pancreatic cancer mainly occurs in people over 60. If it is diagnosed at an early stage, then an operation to remove the cancer followed by chemotherapy with or without radiation therapy

This lecture is drawn from the continuing medical education program Finding Hope: Prevention, Early Detection and Treatment of Pancreatic Cancer, Nov, 2011. Robert P. Jury, MD Cystic Neoplasms of the Pancreas:

UNIVERSITY OF JORDAN FACULTY OF MEDICINE DEPARTMENT OF PATHOLOGY, MICROBIOLOGY AND FORENSIC MEDICINE OUTLINES OF PATHOLOGY FOR REHABILITATION STUDENTS First lecture Chapter 1: Cell injury, cell death and

DYSPEPSIA, HEARTBURN AND ULCERS What is Dyspepsia? Dyspepsia can be translated as bad digestion and is commonly called indigestion. It is a term that is often used by doctors to describe a set of symptoms.

As a patient you must be adequately informed about your condition and the recommended surgical procedure. Please read this document carefully and ask about anything you do not understand. Please initial

HOW I DO IT (EMR) in the esophagus AUTHORSHIP How I do it: Horst Neuhaus, MD Department of Internal Medicine Evangelisches Krankenhaus Düsseldorf Germany Comment Hiroyasu Makuuchi, MD Professor and Chairman

Nash Heartburn Treatment Center a division of Nash Health Care NHCS Mission Statement: To provide superior quality health care services and to help improve the health of the community in a caring, efficient

QuickTime and a decompressor are needed to see this picture. QuickTime and a decompressor are needed to see this picture. Hiatal Hernia with Complications of Gastric Volvulus Josué Zapata, HMS III Gillian

Informed Consent for Laparoscopic Roux en Y Gastric Bypass Patient Name Please read this form carefully and ask about anything you may not understand. I consent to have a laparoscopic Roux en Y Gastric

Program Overview The University of Hong Kong Department of Surgery Division of Esophageal and Upper Gastrointestinal Surgery Weight Control and Metabolic Surgery Program The Weight Control and Metabolic

Diverticular Disease of the Colon EPIDEMIOLOGY Overall prevalence - 12% to 49% Increases with age < 10% in those younger than 40 years > 50% to 66% of patients 80 years As common in men and women Men -

20 MOST FREQUENTLY ASKED QUESTIONS ABOUT COLON CANCER ANSWERED What causes a polyp to form? The exact causes of polyps are uncertain, but they appear to be caused by both inherited and lifestyle factors.

Laparoscopic Gall Bladder Removal Gallbladder removal is a common surgical procedure all over the world. Today, gallbladder surgery is performed laparoscopically (key-hole surgery). The medical name for

SOD (Sphincter of Oddi Dysfunction) SOD refers to the mechanical malfunctioning of the Sphincter of Oddi, which is the valve muscle that regulates the flow of bile and pancreatic juice into the duodenum.